Provider Demographics
NPI:1508959594
Name:WIDENER, MARGUERITE S (LCSW)
Entity Type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:S
Last Name:WIDENER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:
Other - Last Name:WIDENER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:2558 ROOSEVELT ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1672
Mailing Address - Country:US
Mailing Address - Phone:760-522-0710
Mailing Address - Fax:
Practice Address - Street 1:1582 W SAN MARCOS BLVD STE 105
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078
Practice Address - Country:US
Practice Address - Phone:760-522-0710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0054671041C0700X
CA733361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106520Medicaid